Johns Hopkins University Press, 2011. 175 pages.
When we treat diagnosis as simply a medical issue, we mask the tremendous social power involved in putting a name to human suffering. When we transform phenomenological experiences into discrete labels and then treat those labels as reality, we cram those experiences into neat boxes that may not adequately fit or hold them. When we view clinical assessment and diagnostic decision-making as a sober, objective assessment of evidence, we obscure the interpretive dimensions inherent in clinical reasoning. And yet when we receive a diagnosis, it can unlock access to understanding, resources, and empathy in the face of the uncertainty of illness and even death.
Rather than balk at these issues, Annemarie Jutel, in her book Putting a Name to It, confronts the protean character of diagnosis head on. The book’s central conceit is that diagnosis is a complex phenomenon, with effects that ripple far beyond the doctor’s office. As such, Jutel eloquently issues the clarion call for social scientists to take on diagnosis as an object of analysis in its own right. In doing so, she reveals the insight and intrigue available to those willing to scratch the surface of this often taken for granted practice.
Diagnosis encompasses two related, but distinct aspects. First, we can think of diagnosis as a label, by which we classify, categorize and identify symptoms, ailments, and distresses. The label itself has power to organize experiences, determine future courses of action, open access to needed resources, and provide identities around which to mobilize politically. But we can also address diagnosis as an act, an interpretive process that unfolds in the particular interaction of the doctor/patient. Here patient testimony is focused and narrowed by the imperative to “think” through personal accounts of distress in a particular way. Meaning is imposed on disparate information in an interaction characterized by power inequality. A patient enters the interaction with a diffuse set of concerns – physical, psychological, and social – and if all goes smoothly, leaves with a tidy diagnosis. Rather than artificially parse the two sides of diagnosis – recognized categories of pathological conditions and the deliberate judgment by which these categories are affixed – Jutel discusses them in tandem. This decision trades some clarity for a nuanced, albeit messier, description of what diagnosis is and does.
To the topic, Jutel brings an unrelenting sociological imagination in order to counteract commonsense notions of diagnosis. “Diagnoses are presented as facts of nature, yet they hide a deeply grounded, socially negotiated genesis,” she writes (p. 2). Her orientation is that of a moderate social constructionist. She does not deny that people get sick, but does insist that are interpretations of these experiences are shaped by our social position, cultural milieu, and the distribution of power. For her, “diagnoses do not exist ontologically. They are concepts that bind the biological, technological, the social, the political, and the lived,” (p. 13).
Each chapter takes on a different aspect of diagnosis. The first chapter examines the social process of categorizing and classifying diseases, using an array of examples like the Diagnostic and Statistical Manual of Mental Disorders (DSM) to expose this process as interpretive and contingent. Nature doesn’t break things into discrete categories, people do, and how they do so has important social implications. Chapter 2 counters the commonsense notion of diagnoses as objective readings of facts, by showing how our construction of diagnoses are shaped by moral and cultural evaluations. Chapter 3 hones in on the practice of diagnosis, exploring the patient/doctor interaction and demonstrating how power dynamics shape the meaning making on the level of interaction. The next chapter turns to the larger politics of diagnosis, by examining the mobilization behind problematic, or contested diagnoses. Here we see how patient and lay groups assert claims to diagnoses, developing diagnostic identities and mobilizing for their recognition in the face of physician resistance. Chapter 5 turns to the selling of diagnoses by various social actors, or “engines”. This is where pharmaceutical companies rear their ugly heads as profiteers of “disease mongering”. Finally chapter 6 returns to the process of making a diagnosis by examining the crucial role of technology in constructing diagnoses.
Jutel’s analysis is sprawling, as she uses a “bouquet of examples” (p. 101) to build her arguments. She takes insights where she can find them, drawing not only from social science research, but also collecting examples from literature, memoirs, historical monographs, memoirs, her own personal experience, etc. This breadth of source material gives the book richness, but often at the expense of depth. Throughout there are moments in which she seems to skirt by potential paths of exploration. Too often the reader encounters something interesting, only to find it quickly discarded as Jutel breezes to the next topic. Indeed, the book’s strongest portions are when Jutel dives into particular cases (see her examination of the cultural and moral valences of overweight and infant death in chapter 3 or her discussion of the politics and economics driving female hypoactive sexual desire disorder (FHSDD) in chapter 5). And Jutel can be a bit vague in promoting her “diagnostic perspective”, failing to define it in an explicit way.
Putting a Name to It is hard book to pigeonhole. Part meditation, part programmatic statement, part intimate reflection, part analytical call to arms, and part sprawling literature review, this accessible book can be read differently by different audiences – anthropologists, sociologists, medical researchers, doctors, patients, the curious, etc. – with each picking up invaluable insights resonant to their particular interests. I read it as a stimulating meditation on the multiple dimensions of diagnosis. Still Jutel’s agenda is clear: to convince the reader that diagnosis warrants further investigation. Bursting with insights, the book’s true orientation is toward the future. Jutel is not interested in getting in the final word but rather raising provocative questions and suggesting opportunities for subsequent research. In this the book is an unqualified success.
Owen Whooley is assistant professor of sociology at the University of New Mexico. His research focuses on medical professionals, specifically the politics of knowledge involved in the establishment of medical expertise. His book, Knowledge in the Time of Cholera (University of Chicago Press, 2013) explores how the modern American medical profession emerged out of an intellectual crisis produced by recurrent cholera epidemics in the 19th century and the struggles over medical knowledge between medical sects that followed in their wake.